AFFORDABILITY AND CONSUMPTION OF ALCOHOL AND HEALTHProf. MUDr. Bohumil Fišer, CSc., and col.

PUBLICATION OF THE CZECH TECHNOLOGICAL FOOD PLATFORMFascicle number 2

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List of authors:Prof. MUDr. Bohumil Fišer, CSc.Physiological Institute of the Masaryk University in Brno,former Minister of Health of the Czech Republic

Doc. MUDr. Milada Emmerová, CSc.Plzeň District Commissioner,Head of the Hyperbaric Medicine Unit at Pilsen Teaching Hospital,former Minister of Health of the Czech Republic

Prof. MUDr. Jaroslav Racek, DrSc.Head of the Institute of Clinical Biochemistry and Haematology at Pilsen Teaching Hospital

MUDr. Simon Jirát2nd Internal Clinic – Cardiology and Angiology Clinic of the 1st Medical Faculty of Charles University and General Teaching Hospital in Prague

Doc. MUDr. Jaroslav Zvěřina, CSc.Head of the Sexology Institute of the 1st Medical Faculty of Charles University and General Teaching Hospital in Prague,former deputy of the European Parliament

Booklet has been compiled within priority‘s framework of Czech technological platform „Food and Health“ in co-operation with the Czech republic‘s Food Chamber and financially supported by The Agricultural Department of the Czech republic

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Affordability of alcohol has recently been a much discussed issue in the European Union. Politicians who would like to reduce the affordability of alcohol mainly argue with its positive impact on adolescents getting drunk (binge drinking). In the politics it is correct that politici-ans emphasize the arguments that support their intentions and leave the critical arguments to the opposition. However, in the scientific approach, it is necessary to take into accountall the arguments and try for their objective evaluation. Nobody doubts that high alcohol consumption has a negative impact on health, but at the same time it has been proven that moderate drinking of alcohol reduces the risk of cardiovascular diseases. The negative impact of these diseases on mortality and the quality of life of patients who suffer from them in the developed countries is greater than with any other groups of diseases. This fact became the incentive to write this text representing an analysis of statistical data from the

United Kingdom and the Czech Re-public. The data from the United Kingdom were taken from a re-cent study perfor-med by the British Medical Associa-tion. (Diagram 1).

One of the charts in this study demonstrates the same cour-se of the affordability level and the quantity of alcohol con-sumed between 1980 and 2006 (Diagram 2). In this chart the scale level of affordability, as well as the amount of alcohol consumed do not start with the zero value. If the same data are transferred to a graph where the scale starts with zero, and the affordability and quantity of alcohol consumed in 1980 taken where the time series start as 100%, a different image

Diagram 1

THE AFFORDABILITY OF ALCOHOL AND CONSUMPTION OF ALCOHOL PER CAPITAAGED 15 AND OVER, UK, 1980-2006

Source: Statistics on alcohol: England 2007 (The Information Centre, 2007), Statistical handbook 2007 (British Beer and Pub Association, 2007)

180

160

140

120

100

80

60

12

11.5

11

10.5

10

9.5

9

8.5

8

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year

AffordabilityConsumption

Affo

rdab

ility

(100

= 1

980

valu

e)

Litr

es o

f pur

e al

coho

l per

cap

ita (a

ged

15 a

nd o

ver)

Diagram 2

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is created (Diagram 3). A 60% increase in the level of affordabi-lity is equivalent to about 20% increase in the amount of alcohol consumed. Additional data from the British study are summari-zed in the following picture (Diagram 4). The graph shows that groups with higher income consume alcohol in larger quantities than those with lower income, which again demonstrates the effect of affordability on the consumption of alcohol.

However, from the quantitative point of view it is obvious that affordability is much of a lesser issue among the higher income groups and that it greatly exceeds the affordability of the low-

-skilled workers, while the differences in the amount of alcohol consumed are not great.

In addition to the data from 1980 and 2006 having been discussed already, the Table 1 also con-tains additional data from the British stu-dy comparing alco-hol consumption in

ALCOHOL AFFORDABILITY

AFFORDABILITY1980-2006100-165 %

CONSUMPTION1980-2006

9.4-10.9 liters 100-117 %

200 pound/week800 pound/week100-400 %income/household

17.822.1

100-124males

6.112.2

100-200females

u/wu/w%

Table 1

Source: General household survey 2006 (Office for National Statistics, 2008)

Social-economic classification

ADULTS (AGED 16 AND OVER) DRINKING IN THE LAST WEEKBY SOCIO-ECONOMIC CLASSIFICATION, GREAT BRITAIN, 2006

80

70

60

50

40

30

20

10

0

Managerial and professionalIntermediateRoutine and manualAll adults

Perc

enta

geDrank last week Drank on five or

more daysDrank over 4-3

units onat least one day

Drank over 8-6 units on

at least one day

Diagram 4

AFFORDABILITY AND ALCOHOL CONSUMPTION IN THE UK180

160

140

120

100

80

60

40

20

0

1980

1983

1986

1989

1992

1995

1998

2001

2004

% (1

00 =

198

0 va

lue)

Year

Affordability

Alcohol consumption

Affordability is matched by the real value.

Diagram 3

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households whose incomes are several times different. Shown is an income in pounds per week and quantities of consumed alcohol for men and women in the British measuring units. The data again demonstrate that affordability of alcohol affects alcohol consumption

relatively little. Other images are related to the Czech Republic and the data were

taken from the Czech Statistical Office. The image (Diagram 5) showsa slight increase in alcohol consumption between 1990 and 2006 for all types of alcoholic beverages, beer, wine and spirits.

The statistical data enable us to compare the level of affordability between 1996 and the present (Diagram 6). We see a much larger increase in the degree of affordability than the increase in alcohol consumption. To compare the data from the same period we again use the chart from the United Kingdom (Diagram 7), where the va-lues from 1996 are taken for 100%. We see a similar image as in the Czech Republic. The quantity of alcohol consumed is growing more slowly than the level of its affordability.

CONSUMPTION IN TERMS OF PURE ALCOHOL – CZECH REPUBLIC

YEAR

Litr

e pe

r cap

ita p

er y

ear

6

5

4

3

2

1

01985 1990 1995 2000 2005 2010

BEER

SPIRITS

WINE

Diagram 5

AFFORDABILITY AND ALCOHOL CONSUMPTION IN THE CZECH REPUBLIC

YEAR

160

140

120

100

80

60

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

AffordabilityBeer (pure alcohol litre per capita)Alcohol (litre per capita)%

(100

= 1

996

valu

e)

Diagram 6

AFFORDABILITY AND ALCOHOL CONSUMPTION IN THE UK

Year

140

120

100

80

60

40

20

0

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Alcohol consumptionAffordability

% (1

00 =

199

6 va

lue)

Diagram 7

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ELASTICITY OF DEMAND FOR ALCOHOL

Affordability increase 10 %CZ 1996-2006UK 1980-2006UK 1996-2006

UK - household maleUK - household female

Consumption increase1.79 %2.49 %3.29 %0.80 %3.33 %

Table 2

AFFORDABILITY OF ALCOHOLDemand curve for alcohol is flet,the demand is relatively inelastic

Relationship between the dose ofalcohol and the health effect is

expressed by J-curve

Diagram 8

J CURVE20

15

10

5

0

-5

-100 2 4 6 8 10 12 14 16

Alcohol dosis [arbitrary unit]

Hea

lth h

am (b

enef

it) [a

rbitr

ary

unit]

Table 2 summarizes the data from the Czech Republic and the United Kingdom. A 10% increase in the level of affordability corre-sponds to an increase in consumption between 0.8 and 3.33% in different time series or income groups.

All these tests show that the demand curve for alcohol is flat, while the demand for alcohol is relatively inflexible.The available data suggest that changes in affordability of alcohol will have only a small effect on the quantity of alcohol con-

sumed. But even a small step is useful if it is a step in the right direction. However, there are facts that show that in the relation between alcohol and health it is a step in the wrong direction.

With some exceptions the effect of all substances on the health is illustrated by the J curve. There is a certain optimal dose and the dose which is below or above has a negative impact on health in comparison with the optimal dose. The high doses have worse effects than the zero doses. The curve has the shape of let-ter J (Diagram 8). This applies to all the nutritional substances, minerals, vitamins and medications. Alcohol is no exception. (Such exception is inhalation of various substances during to-bacco smoking. I am not aware of any positive effects of low doses.)

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The positive effect of alcohol on the risk of mortality caused by cardiovascular diseases has been demonstrated in many studies, the meta-analysis (taken from the Circulation Journal) is presented in the following four figures. The figure (Diagram 9) relates to wine.Prospective and retrospective epidemiological studies suggest the same. People consuming wine are less likely to die from cardiova-scular disease than people who are abstaining. Image (Diagram 10), represents information about beer. Again, people who consume beer, have lesser likelihood of death from cardiovascular disease than people abstaining. The data do not allow comparison between beer and wine. The difference between the effects on health for beer and wine could not be ascertained.

0.50.40.3 0.6 0.7

Protective effect Risk effect

0.8 0.9 1 1.1

Kozararevic, 1980 (17)

Friedman, 1986 (18)

Rimm, 1991 (19)

Klatsky, 1990 (20)

Wannamethee, 1999 (21)

Prospective studies

Roseberg, 1981 (22)

Kaufman, 1985 (23)

Marques Vidal, 1996 (28)

Sacco, 1999 (24)

Gaziano, 1999 (25)

Thrift, 1999 (26)

Cleophas, 1996 (29)

Brenner, 2001 (27)

Case-Control studies

Overall

Diagram 9

0.50.40.3 0.6 0.7

Protective effect Risk effect

0.8 0.9 1 1.1

Kozararevic, 1980 (17)

Friedman, 1986 (18)

Rimm, 1991 (19)

Klatsky, 1990 (20)

Wannamethee, 1999 (21)

Prospective studies

Roseberg, 1981 (22)

Kaufman, 1985 (23)

Sacco, 1999 (24)

Gaziano, 1999 (25)

Thrift, 1999 (26)

Brenner, 2001 (27)

Theobald, 2000 (30)

Biachi, 1993 (31)

Simons, 1996 (32)

Salonen, 1983 (33)

Case-Control studies

Overall

Diagram 10

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The image (Diagram 11) shows the curve J for wine. The data do not allow the construction of the curve at higher doses. In case of beer it was impossible to construct the curve J on the basis of this meta-analysis (Diagram 12). Therefore, I used the data from

Diagram 11

Best-fitting model for wine effect(R2 = 0.54 versus R2 = 0.27 for the linear modelwith a positive linear term; P = 0.34), usingdose-response curves in 7 prospective studies.Parameters of the model wereß1 = -9.9 ± 4.4 x 10-4 (P = 0.042) andß2 = 0.0067 ± 0.0023 x 10-4 (P = 0.013). The best-fitting model using data from the 3 case-controlstudies was a quadratic model that was not sta-tistically significant with a positive linear term(P = 0.16) and a negative quadratic term(P = 0.091). Horizontal lines represent the 95 % CI.

Rela

tive

Risk

(95

% C

I)

Intake of wine (ml/day)

Intake of ethanol (g/day)

0

0 6 12 18 24 30 36 726660544842

100 200 300 400 500 600 700 800

1.4

1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

0

Diagram 12

RRs or odds ratios for differentcategories of beer intake (dose-responsecurves). The black line indicates the pre-dicted model using data from all studies.Considering all the studies, the best-fitting model was not statistically signifi-cant (R2 = 0.64) including a negative linearterm (ß1 = -1.8 ± 2.9 x 10-4; P = 0.54); theinclusion of a quadratic term did notimprove the fit. In prospective studiesß1 = -1.0 ± 4.3 x 10-4 (P = 0.83)

Rela

tive

risk

Beer intake (ml/den)0 200 400 600 800 1000 1200 1400 1600 1800

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0

34353836393742Model

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the Czech study, which was co-authored by Prof. Sir Michael Marmot (Diagram 13). It shows that the optimal dose for men is 1 liter of beer per day, which is equivalent to 30 g alcohol per day. At 60 g of alcohol per day, mortality rates are comparable to the men who do not consume any alcohol.

Important are the data about serious negative consequences of excessive alcohol consumpti-on, as shown in the statistics of people treated for alcoholism. These are shown in the next ima-ge (Diagram 14) together with the statistics on drug addiction treatment. The slight increase in alcohol consumption during 1999 and 2006 was not accompanied by the growth of alcohol addic-tion among men (the data from previous years fall into the transformation of health care and are not fully comparable). There is a rise in the number of women treated for alcohol addiction. The most striking is the increase in the number of patients treated for drug addiction, both men and women.

BEER CANSUMPTION AND MYOCARDIAL INFARCTION1.4

1.2

1

0.8

0.6

0.4

0.2

00 2 4 6 8 10 12 14Re

lativ

e ris

k of

myo

card

ial i

nfar

ctio

n

Litre per week

Diagram 13

PATIENTS TREATED FOR ALCOHOL AND DRUGS IN THE CZECH REPUBLIC

Patie

nts

per y

ear

Year

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

01988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Alcohol maleAlcohol femaleDrugs maleDrugs female

Diagram 14

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The next picture (Diagram 15) shows the number of hospitalizations, the conclusions are the same as in the previous chart.

Beer consumers are exposed to intense advertising campaigns, the spirit adverti-sing is less intense and the wine advertising is practically absent. At the same time the cases of alcohol addiction are stagnating. There is no advertising for drugs; the sale is being prosecuted by specialized security services and the apprehended face heavy prison sentences. Despite that, the numbers of drug addicts are growing. These facts lead to the conclusion that it is not advertising and affordability but the changed lifestyle that leads to addiction with all negative effects both on individuals and on society.

Diagram 15

HOSPITALIZATION FOR ALCOHOL AND DRUGS IN THE CZECH REPUBLIC

Year

Patie

nts

per y

ear

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

019901988 1992 1994 1996 1998 2000 2002 2004 2006 2008

Alcohol maleAlcohol femaleDrugs maleDrugs female

AFFORDABILITY OF ALCOHOL II

ALCOHOL - Big increase of affordability - small increaseof consumption - stagnation of alcohol - caused psychiatricdisorder DRUGS - limited affordability - increase of misuse - increaseof drugs-related disorders Not advertising but change of lifestyle is respontiblefor trends

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The British Medical Society in the below study formulates ten recommendations for reducing the harmful effects of alcohol on health (Table 3). The recommendations 4 to 10 are fully acceptable. The first three recommendations are related to licensing, taxationand advertising. These certainly represent a significant impact on consumers, who drink alcohol in moderation. Statistics in the nextpicture (Diagram 16) show the distribution of alcohol consumption among EU citizens. It shows that 90% of drinkers consume alcohol in amounts which represent the reduction in the risk of cardiovascular diseases. These facts support the view that the measures in the area of licensing, advertising and affordability have a negative impact on the majority of drinkers, and only marginally affect the consumers who drink excessively.

Table 3

RECOMMENDATIONSThere should be strong support for European Union, World Health Organisation and

World Health Assembly initiatives and policies aimed at reducing alcohol-related harm to individual and public health.

Lobby for, and support the World Health Organisation in developing and implementing a legally binding international treaty on alcohol control in the form of a Framework Convention on Alcohol Control. This should include provisions for:

- regulation of the availability of alcohol through licensing- increased taxation on alcoholic beverages- statutory regulation of alcohol advertising, promotion and sponsorship- programmes aimed at educating the public of the harms associated with alcohol

misuse- legislation to discourage drink-driving- appropriately funded and resourced treatment services- enforcement of the legal responsibility of retailers to sell alcoholic beverages in

accordance with legislation- promoting research and the exchange of information among countries- establishing a priority for public health considerations in the regulation of international

alcohol commerce- international cooperation to combat illegal production and trade in alcohol.

Diagram 16

DISTRIBUTION OF ALCOHOL CONSUMPTION EU 2006

Drinks per day

70

60

50

40

30

20

10

0

%

<1 >42 to 31 to 2

BMA RECOMENDATIONS 1-3(licensing, taxation, advertising)

ignore the positive effect of alcohol on health, punish 200 mil. of people in EU who drink moderately. exert low pressure (because of inelasticity of demand) on 20 mil. who drink excessively.

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I believe that the stress on licensing, taxation and advertising unfortunately diverts us from other areas of the nega-tive impact of alcohol on health. Alcohol increases the risk of colorectal cancer (Czech Republic features the highest mortality for colorectal cancer in the world), the risk of breast cancer in case of women and prostate cancer in case of men. The increased risk of colorectal cancer is responsible for the reduction of the risk of cardiovascular diseases, but the number of persons affected by colorectal cancer represents 10% of persons affected by cardiovascular diseases. Even at zero alcohol consumption (which is unrealistic and unwarranted considering the cardiovascular diseases) the frequency of colo-rectal cancer would decrease only slightly. The impact on breast and prostate cancer is even smaller. All three types of carcinomas are slow-growing and are fully curable in the early diagnosis. A good strategy to fight these diseases is preventative examinations,colonoscopy testing for cancer of colon and rectum, mammography for breast cancer and monitoring of prostatic antigen for pro-state cancer. This strategy cannot be selected in the fight against lung cancer. There are no means of early diagnosis, therapy failsin most cases and no smoking is the only proper prevention. Even ten years after the initiation of machine production of cigarettes at the beginning of the twentieth century lung cancer was a rare disease. Given the fact that alcohol addiction is genetically influ-enced, it would be appropriate to increase the number of health facilities providing especially the genetically predisposed patients with psychological assistance. The lifestyle of young people, which includes getting drunk and drug abuse, needs to be modified byproviding opportunities for entertainment and sports and non-stigmatizing punishing of excesses.

RECOMMENDATIONBMA 4-10 recommendation support

Improvement in preventative measures in oncologyBrest cancer – mammography

Colorectal carcinoma – colonoscopy Prostate cancer – PSA monitoring Improvement in psychologic and

psychiatric services Punishing (fast and non-stigmatizing) of

excessive alcohol consumption by younger generations

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Bibliography:1. Meta-analysis of wine and beer consumption in relation to vascular risk Autor(s): Di Castelnuovo A, Rotondo S, Iacoviello L, et.al. CIRCULATION, vol. 105., Issue: 24. p.: 2836-2844, June 18, 2002.2. Effect of beer drinking on risk of myocardial infarction: poulation based case-control study. Autor(s): Bobak M, Skodova Z, Marmot M. BRITISH MEDICAL JOURNAL, vol. 320, Issue: 7246, p.: 1378-1379, May 20, 2000.3. Attitudes towards Alcohol, Special Eurobarometer 272b/Wave 66.2 – TNS Opinion & Social. March 2007.4. Alcohol misuse: tackling the UK epidemic. February 2008, ISBN: 978-1-905545-26-1.

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Published by ENIGMA, spol. s r. o., forThe Czech technological food platform in co-operation with The Food Chamber of the Czech republic,Počernická 96/272, 108 03 Praha 10 – Počernice

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ISBN 978-80-86365-05-3

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Published by ENIGMA spol. s r. o., forThe Czech technological food platformin co-operation with The Food Chamber of the Czech republic

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ISBN 978-80-86365-05-3